<p> 1 WESTERN KENTUCKY UNIVERSITY</p><p>Research and Educational Animal Use Protocol</p><p>This application must be completed for each separate animal use project involving research, education or any other related animal use activity. The completed form must be submitted to the Chairperson of the Institutional Animal Care and Use Committee. Contact Dr. Noah Ashley, IACUC Chair. [email protected] </p><p>Any significant change in an approved protocol requires reapplication using this form. Attach a copy of the original approval and complete only those items on this form which have been changed.</p><p>Principal (Faculty) Investigator: Telephone: </p><p>Student Investigator(s):______Telephone: </p><p>______Telephone: </p><p>Department: ______</p><p>Project Title: ______</p><p>______</p><p>CITI Program Training Completion Date: Contact Dr. Noah Ashley, IACUC Chair. IACUC applicants are to satisfy the CITI modules pertaining to the intended research and will be directed by the IACUC board.</p><p>Project Duration (Dates):______to ______</p><p>Funding Source(s): ______</p><p>Project Description: (Brief, concise but include all animal related procedures. (Attach on separate sheet.)</p><p>Rev. October 2016 2 Complete the following:</p><p>1. Personnel Using Animals: (Names, specific experience or training relevant to the proposed project).</p><p>2. Standard Operating Procedures and Policies Governing Project: (AT & T Policy, NIH Policy, Animal Welfare Act, etc.)</p><p>3. Hazardous Agents Used Involving Animals: (List all which are a human risk).</p><p>4. Animals Common name ______No.______Sex______</p><p>Genus: Species:</p><p>Rationale for species and the number used:</p><p>Source: Housing location:</p><p>Research Use Site Other than CEBS 3113: (How long will animals exist at the experimental site?)</p><p>5. Animal Health Surveillance Measures:</p><p>Rev. October 2016 3</p><p>6. Animal Physical Restraint Methods:</p><p>7. Animal Discomfort, Distress, or Pain:</p><p>Will distress or pain occur? ____ Yes ____ No ____ Don't know</p><p>If answered yes above, please complete the following:</p><p>Drug(s) anesthetic, analgesic, sedative, tranquilizer to be used to relieve distress or pain:</p><p>Dosage of the drug(s):</p><p>Route/Frequency of drug use:</p><p>If distress or pain cannot be alleviated through drugs, please justify thoroughly below:</p><p>Will deprivation occur during housing? _____ Yes _____ No</p><p>If yes, justify:</p><p>Rev. October 2016 4 8. Animal Surgery: ______Survival ______Non-survival ______Aseptic</p><p>Has any animal been used, or will be used, in more than one major operative procedure from which it is allowed to recover? ______Yes ______No </p><p>If so, provide justification please:</p><p>Procedures:</p><p>Post-operative care:</p><p>9. Euthanasia:</p><p>Method:</p><p>Drug: ______Dosage: ______Route: ______</p><p>Rationale for selecting the above:</p><p>10. Veterinarian Consultation:</p><p>Have you consulted the University's Attending Veterinarian on this protocol? ______Yes ______No</p><p>11. Alternative Procedures: Document alternative procedures you considered that relieve more than momentary or slight pain or distress to animals. Outline the methods and give sources (e.g., biological abstracts, Index Medicus, etc.) that were used to determine that alternatives were not available.</p><p>Rev. October 2016 5</p><p>12. Provide below a written narrative description of methods and sources that were used to determine that the proposed activities do not unnecessarily duplicate previous experiments:</p><p>13. Disposition of Animals:</p><p>Specify handling of carcasses:</p><p>Specify any particular necropsy requirements or other needs:</p><p>Rev. October 2016 6</p><p>I certify that I fully understand University policy concerning necessary and appropriate training for research personnel using animals and that every person engaged in this research project has been or will be thoroughly trained in the methods or procedures to be used. All such personnel have been made familiar with the NIH Guide for the Care and Use of Laboratory Animals and the requirements of the amended Animal Welfare Act. I agree to make every reasonable effort to ensure the proper conduct of all persons assisting in this research project.</p><p>______Faculty Signature Date</p><p>______Student Signature Date</p><p>IACUC ACTION [ ] Approved [ ] Conditionally Approved [ ] Not Approved</p><p>Meeting Date: ______</p><p>Comments:</p><p>______IACUC Chairperson or Designated Reviewing Member Date</p><p>Rev. October 2016</p>